Considerations for Extended Spectrum Beta-Lactamase (ESBL)-Producers in Nursing Homes

Extended Spectrum Beta-Lactamase (ESBL)

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As the COVID-19 pandemic was challenging public health and infection preventionists, multidrug-resistant organisms (MDROs) lurked quietly in the background. Although not as well-known as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) or as feared as Candida auris, extended spectrum beta-lactamase (ESBL)-producing Enterobacterales have been identified by the Centers for Disease Control & Prevention (CDC) as a serious risk to public health. Infection preventionists (IPs) in nursing homes must thus gain a better understanding of how to manage this additional threat.

ESBLs on the rise

ESBL-producing Enterobacterales (ESBL-Es) received an unfortunate honorable mention in the 2022 CDC special report COVID-19: US Impact on Antimicrobial Resistance. From 2019 to 2020, the US saw a 32% increase in these infections in hospitalized patients.¹ In 2017, there were 197,00 new ESBL cases, which was a 53% rise from 2012.² Also identified as rapidly spreading through nursing homes were ESBL-producing Escherichia coli.³ Because the health care continuum involves patient movement between acute care, short-stay rehab, long-term care, and other facilities, it is critical that infection preventionists in nursing homes be aware of this MDRO.

An ESBL is an enzyme produced by certain strains of gram-negative bacteria that protects bacteria from many commonly prescribed antibiotics, which is great news for bacteria but bad news for the patient, clinical treatment options, and public health overall. First identified in Greece in the early 1960s, ESBLs have been expanding their families and geographic reach ever since. The first case in the US was reported in 1988.⁴ ESBLs continue to strengthen in antibiotic resistance and require treatments other than standard antibiotic regimens.

ESBLs are found in the class of Enterobacteriaceae, common gut bacteria that include E coli and Klebsiella pneumoniae. Exposure to health care, including hospitals or nursing homes, places individuals at greater risk for developing an ESBL. But even without such exposure, ESBLs have been identified in otherwise healthy people, often manifesting as urinary tract infections.⁵ ESBLs are resistant to cephalosporins and penicillin, with carbapenems left as one of the only effective treatments. Although these intravenous antibiotics are often the best treatment, they require venous catheters and often a longer stay. If bacteria become resistant to this last-option drug class, even fewer options will be available.³

Added challenges for nursing homes

Because nursing homes provide long-term care as well as short-stay rehabilitation, they are affected by various factors. Most of their residents are aged over 65 and have multiple comorbidities that impact their immune system, skin, and mucous membranes. In addition, the atypical infection symptoms seen in them may delay infection identification. Creating a home-like environment is essential for individuals who will spend weeks, months, or even the remainder of their lives at the facility. With more shared residential areas than other settings, nursing homes find it difficult to contain infections. Private rooms, especially in older facilities, are far less common than shared rooms, which may be designed to accommodate up to 4 residents. More than half of them will receive an antibiotic over the course of a given year. Of those, 40% to 75% do not meet the clinical criteria for appropriateness of use or are prescribed an incorrect dose or length of treatment.^6,7

The Basics

As with all MDROs, prevention and containment of ESBLs begins with good hygiene. ESBLs are primarily spread by direct contact with infected body fluids, including those found on surfaces and equipment. Just as hand hygiene is essential in health care workers, residents should also be encouraged to wash their hands, especially after using the bathroom and before meals, as ESBLs live and travel in the gastrointestinal tract. A study at the University of Michigan revealed that residents’ hands are often contaminated with MDROs.⁶

Proper cleaning and disinfection, with periodic audits and feedback, will help build adherence to your prevention program. Obtain buy-in from those individuals doing the work by making infection prevention “everyone’s business” and include others who may be interested to collect data and provide reports to peers. Keep everyone in the prevention program involved and aware that environmental services are far more than merely janitorial, and that infection prevention relies on all the dedicated individuals doing this work. They must understand their role in infection prevention, stay up to date on best practices, and have a voice in the decisions made by Quality Assurance & Performance Improvement (QAPI) and the institution’s antimicrobial stewardship program.

The CDC’s Project Firstline offers virtual learning with interactive resources, educational modules, printed materials, and training toolkits improve infection prevention and control beyond hospitals into nursing homes, and other long-term care facilities.⁹ These materials are a great way to educate the staff and keep them up to date.

Precautions

Transmission-based isolation precautions for ESBLs may differ between nursing homes and other health care facilities. Stay connected with and follow recommendations from your health department to stay abreast of current trends.¹⁰ Enhanced Barrier Precautions (EBP) offer direction on how to handle MDRO infection and colonization. If CDC contact precautions don’t apply to a resident with an ESBL per the facility’s protocol, CDC guidelines list them as an “epidemiologically important MDRO,” for which EBP is recommended. The EBP strategy was designed with input from a CDC Healthcare Infection Control Practices Advisory Committee expert group in 2019 and updated in 2022. Besides MDRO infection and colonization for residents when contact precautions don’t otherwise apply, EBP is recommended to be followed with residents who have indwelling medical devices or wounds during “high-contact resident care activities.”¹¹ Because EBP does not require a private room or exclude residents from activities, it may be the ideal option.

Communication

The prompt and accurate sharing of information during care transitions or resident transfers is an essential component of infection prevention and resident safety. When residents are moved between nursing homes, acute care, outpatient clinics, and home care, infection and colonization status information should be prioritized. Have there been times when information about residents coming to your facility has not been provided directly to the clinical staff? Does a physician's office always communicate lab or clinical findings after the resident returns to your facility? On the flip side, can hospital emergency department staff easily discern whether a resident is being treated for an infection or has a history of MDRO colonization? Developing working relationships between the staff responsible for transfers and IPs can bridge the communication gap. Not only is the sharing of infection information best practice, but it can also alert you to current practices and challenges at nearby facilities.

Antibiotic Stewardship

Nursing homes are one of several health care settings that must have antibiotic stewardship programs in place. A 2015 study by Daneman et al found a great deal of variability among 600 nursing homes with respect to antibiotic prescribing and the high antibiotic use associated with increased individual-level risk, even among residents who did not receive antibiotics. Nonrecipients are at an increased risk simply by being at that facility.¹² Recognizing where the facility stands in terms of antibiotic prescribing, zeroing in on opportunities for improvement, and engaging a multidisciplinary team to address problems create a safer environment for everyone. The CDC’s Core Elements of Antibiotic Stewardship for Nursing Homes is a comprehensive toolkit for institutions starting from scratch or looking for materials to address a specific issue related to antibiotic stewardship.⁷

References

1. COVID-19: U.S. impact on antimicrobial resistance, special report 2022.Centers for Disease Control and Prevention. June 2022. Accessed Nov 21, 2022. https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf
2. Castanheira M, Simner PJ, Bradford PA. Extended-spectrum β-lactamases: an update on their characteristics, epidemiology and detection. JAC Antimicrob Resist. 2021;3(3):dlab092. doi:10.1093/jacamr/dlab092
3. ESBL-producing Enterobacterales in healthcare settings. Centers for Disease Control and Prevention. Updated Nov 22, 2019. Accessed Nov 21, 2022. https://www.cdc.gov/hai/organisms/ESBL.html 
4. Ghafourian, S., Sadeghifard, N., Soheili, S., & Sekawi, Z. Extended spectrum beta-lactamases: Definition, classification, and epidemiology. Curr Issues Mol Bio. 2015;17:11-22.
5. Antibiotic resistance threats in the United States, 2019.Centers for Disease Control and Prevention. Reviewed December 2019. Accessed Nov 21, 2022. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf
6. Montoya A, Cassone M, Mody L. Infections in Nursing Homes: Epidemiology and Prevention Programs. Clin Geriatr Med. 2016 Aug;32(3):585-607. doi:10.1016/j.cger.2016.02.004. PMID: 27394025.
7. Core elements of antibiotic stewardship for nursing homes. Centers for Disease Control and Prevention. Reviewed Aug 20, 2021.Accessed Nov 15, 2022. https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html
8. Cao J, Min L, Lansing B, Foxman B, Mody L. Multidrug-resistant organisms on patients’ hands: a missed opportunity. JAMA Intern Med. 2016;176(5):705-706. doi:10.1001/jamainternmed.2016.0142
9. Project Firstline.Centers for Disease Control and Prevention. Updated July 20, 2022. Accessed November 15, 2022. https://www.cdc.gov/infectioncontrol/projectfirstline/index.html
10. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings.Updated May 2022. Accessed November 15, 2022. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html.
11. Implementation of personal protective equipment (PPE) use in nursing homes to prevent spread of multidrug-resistant organisms (MDROs). Centers for Disease Control and Prevention. Updated July 12, 2022. Accessed November 15, 2022.https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf 
12. Daneman N, Bronskill SE, Gruneir A, et al. Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. JAMA Intern Med. 2015;175(8):1331-1339. doi:10.1001/jamainternmed.2015.2770